road to health diabetes program
TRANSCRIPT
University of Massachusetts AmherstScholarWorks@UMass Amherst
Doctor of Nursing Practice (DNP) Projects College of Nursing
2013
Road to Health Diabetes ProgramAlicia JohnsonUniversity of Massachusetts - Amherst
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Road to Health Diabetes Program
A Capstone Project Presented
by
Alicia Johnson
Submitted to the Graduate School of the
University of Massachusetts-Amherst in partial fulfillment
of the requirements for the degree of
DOCTOR OF NURSING PRACTICE
May 30, 2013
School of Nursing
Approved as to style and content by
Jean DeMartinis, PhD, APRN, FNP, School of Nursing Committee Chair
Sharon Mills-Wisneski, PhD, RN, School of Nursing Committee Member
Vivian Wilson, MD, Project Mentor
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Abstract
Diabetes is a major health problem in the United States. Individuals with diabetes are at
greater risk of developing other health problems such as heart or kidney disease. African
Americans are at 1.8 times greater risk of developing diabetes, and they suffer more severe
consequences and complications from the disease. One major reason for poor outcomes in
African Americans with diabetes is a lack of knowledge and understanding of the disease
process and sequelae of diabetes. This DNP scholarly project focused on implementing a
culturally sensitive diabetes education program in the hope of improving glycemic control
among participants. The project was implemented in a rural clinic outside of Oklahoma
City. Prior to implementation of the project, all healthcare providers and their staff were
informed about the program and asked to refer their patients to it. The DNP scholarly
project occurred over a five-week period, and each session lasted from 1---3 hours
depending upon the depth of the information covered as well as the participation level. In
the first week, the sessions were accomplished on a one-to-one basis in an effort to establish
a personal connection with participants and to build rapport with them. Those individuals
who returned for more than one session experienced an improvement in their HgA1c at the
completion of the DNP scholarly project: One participant had a 2 point decrease while the
other return participant had a .2 decrease. All participants had an increase of 40---50% of
their pre- and post-test scores.
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Problem Statement
Diabetes is a major health problem in the United States (US), where approximately
8.3% of the population has diabetes. Individuals with diabetes are at greater risk of
developing heart disease, stroke, blindness, kidney disease, neuropathy, and need for
amputations. African Americans are at 1.8 times greater risk of developing diabetes, and
they subsequently suffer more severe consequences and complications from the disease.
One major reason for poor outcomes in African Americans with diabetes is a lack of
knowledge and understanding of the disease process and sequelae of diabetes, as well as a
lack of knowledge regarding proper nutrition and compliance with diabetic nutritional
guidelines. These informational deficiencies lead to poor glycemic control. The reasons for
poor glycemic control in African Americans are multifactoral and should be addressed
while investigating the need for a culturally tailored diabetes education and treatment
regimen. These issues must be faced and understood so that providers can design, implement,
and evaluate more efficient and effective diabetes education for African Americans.
Evidence of the Problem
Approximately 25.8 million children and adults in the US have diabetes (American
Diabetes Association, 2011a), roughly 8.3% of the population. Individuals who have diabetes are
at greater risk for developing heart disease, stroke, blindness, kidney disease, neuropathy, and
complications that lead to amputations. Studies have shown that glycemic control can reduce the
risk of developing microvascular complications in individuals with diabetes (Centers for Disease
Control and Prevention, 2011). One group of Americans suffers more than any other from
diabetes, at a greater rate, and experiences more severe consequences of uncontrolled diabetes:
That group is African Americans.
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Approximately 3.7 million African Americans or 14.7% of the African Americans aged
20 or older, have diabetes (American Diabetes Association, 2011b; Office of Minority Health,
2012; Women’s Health.gov, 2012 ). When compared to non-Hispanic whites, African Americans
are approximately 1.8 times more likely to have diabetes. Twenty-five percent of African
Americans over the age of 65 have diabetes. Morever, the complications of diabetes are
particularly severe in this population. Compared to non-Hispanic whites, African Americans are
approximately 50% more likely to develop diabetic retinopathy, they are 2.6–5.6 times more
likely to suffer from kidney disease, and they are 2.7 times more likely to suffer from lower limb
amputation. These statistics indicate that diabetes is a major health threat in the African-
American community. If African Americans continue to exercise poor glycemic control of their
diabetes, these statistics will not improve. Several factors contribute to poor glycemic controls in
African Americans; however, the most important factor is lack of knowledge and understanding
of the disease sequelae regarding diabetes and how to manage diabetes effectively.
Review of Literature
Methods
The Doctor of Nursing Practice candidate (DNP[c]) reviewed relevant research
regarding diabetes in African Americans. This was accomplished by reviewing biomedical
and social science search engines. Seven research engines were used to locate articles dated
2005---2012, with key articles being obtained primarily from CINAHL, Nursing
Journals@Ovid, PubMed, and ERIC. Key terms used to identify potential articles included
diabetes, African Americans, beliefs, perceived risk, complications, fatalism, and diabetes
education. Research articles were selected if they specifically discussed diabetes in the
African-American population; article selection was then reduced by concentrating on those
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found to describe knowledge deficits, African-American beliefs regarding diabetes, and
diabetes educational programs specifically geared toward African Americans.
Lack of Knowledge and Understanding Regarding Diabetes
Skelly and colleagues (2006) conducted a study in which they examined the beliefs that
African Americans held regarding diabetes. This study looked at participants’ knowledge
regarding diabetes in general, preventing diabetes, and whether or not diabetes could be
controlled or cured. Common themes noted in this study regarding the etiology of the disease
included that diabetes was caused from eating too much sugar and that diabetes ran in families.
Those study participants did not draw a parallel between the role that diet and obesity play in the
development of diabetes, and many of them consumed diets that were high in sugar, fat, salt,
grease, and fried foods. They also lacked knowledge and understanding about the curability of
diabetes. The younger participants understood that diabetes could not be cured, while the older
ones, especially men, believed diabetes could be cured with insulin. Most of the participants
were unsure if diabetes could be prevented.
Mann, Leventhal, Ponieman, and Halm (2009) conducted a study to examine the
misconceptions about diabetes and its management among low-income minorities. The
participants were Latinos and African Americans with diabetes who lived in New York City.
Twelve percent believed they had diabetes only when their glucose levels were elevated, and the
majority (56%) felt that their glucose was not elevated until it was over 200. The normal range
for blood glucose for individuals with diabetes is up to 130 when fasting and less then 180 after
eating. Another disturbing finding was that 54% of the participants stated they could feel when
their glucose levels were elevated. While 29% expected their healthcare provider to cure their
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diabetes, the majority felt the health consequences of uncontrolled diabetes were minimal and
that they had little or no control over their diabetes.
In a study conducted by Wenzel, Utz, Steeves, Hinton, and Jones (2005), participants also
disclosed a lack of knowledge regarding elevated glucose levels. They also voiced distrust in
their healthcare providers and in their providers’ ability to know what they had been eating based
upon their blood glucose readings.
Lack of Knowledge Regarding the Complications of Diabetes
Calvin et al. (2011) examined perceived risk of complications in urban African-American
adults with diabetes. The participants were recruited from three inner-city Chicago clinics.
Included were 143 adult (18–75 years old), urban African Americans with diabetes. Fifty percent
or more did not perceive their personal risk of developing complications of diabetes to be high or
even moderate. Amputation, blindness, and kidney disease were ranked lowest of the
participants’ personal perceived risks of the disease. However, a positive relationship was found
between participants who had more symptoms of diabetes and their perceived personal risk of
developing complications.
Cullen and Buzek’s (2009) study attempted to ascertain the risk perceptions of African-
American and Hispanic adults and their adolescent children, all with a known family history of
diabetes. The majority (74%) of the parents in the study were able to identify family history as a
risk factor for developing diabetes; however, less than 25% of the students responded correctly
to this question. An alarming 26% of the parents knew that being overweight was a risk factor
for the development of diabetes, while only 10% of the students considered weight to be a risk
factor. Other areas where lack of knowledge about perceived risk was noted were diabetes
prevention practices and dietary behaviors.
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McKenzie and Skelly (2010) explored the risk perception of developing coronary heart
disease (CHD) in southern African-American females with diabetes. Many of the participants
had a risk factor such as hypertension for developing CHD; however, many did not feel that they
were at risk of actually developing CHD. The participants also did not see the link between past
heart failure, past cardiac events, or having diabetes as a risk for developing CHD. Many felt that
if they had CHD, they would experience some sort of symptoms or pain, and because they had
not experienced any symptoms, they did not have CHD.
These studies reveal that large knowledge deficits and misconceptions continue to exist
among participating African Americans regarding diabetes and its management. The information
gained from these studies may help build a basic foundation for healthcare providers to use when
discussing diabetes with their patients and providing diabetes education. Not only do many
African Americans lack knowledge and understanding regarding the causes of diabetes, but they
also lack knowledge and understanding about the sequelae of diabetes and their risk of actually
developing diabetes or its complications. Not only is disease management of African Americans
with diabetes affected by their beliefs about the disease sequelae but also by their religious
beliefs as well as their beliefs regarding fatalism.
Fatalism in African Americans With Diabetes
Egede and Bonadonna (2003) explored the role that fatalism plays in African Americans
with diabetes. This study was conducted at a large medical center in the southwestern US. Focus
groups made up of 39 consenting African Americans with diabetes were asked general questions
that sought to reveal their beliefs about diabetes and what having diabetes meant to them. The
participants were also asked probing questions regarding their ability to stop or slow down the
progression of diabetes, as well as if they had control over their diabetes. Many of the
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participants felt that diabetes was a generational curse, which was passed from generation to
generation, and that the only way the curse could be broken was to not acknowledge or claim
diabetes.
Walker et al. (2012) examined the effects that diabetes fatalism had on medication
adherence and self-care behaviors in adults with diabetes. The researchers hypothesized that the
concept of fatalism may be more applicable to African Americans than to other ethnic groups
due to their lived experiences in the US. The researchers recruited 378 African Americans with
diabetes, ages 50–64, from two primary care clinics in the southeastern US. This study revealed
that diabetes fatalism was associated with poor medication adherence and self-care behaviors.
These findings suggest that diabetic individuals who exhibit higher fatalistic attitudes may be
less adherent about taking their medications as well as their self-care behaviors. Walker et al.
also found that a lack of knowledge about diabetes care was significantly associated with
diabetes fatalism and that increasing diabetes knowledge in diabetic patients may be a line of
attack to change fatalistic attitudes in diabetic African Americans.
Spirituality in African Americans With Diabetes
Polzer and Miles (2007) examined the spirituality of African Americans with diabetes
and how their relationship with God affects their diabetes self-management behaviors. This study
was conducted in central and eastern North Carolina and contained 29 participants (10 men and
19 women) as well as five Protestant ministers. The religious affiliations of the study participants
included Apostolic (1), Baptist (11), Church of God (2), Episcopal (5), Holiness (3), Methodist
(2), nondenominational (2), Resurrection and Power of Jesus Christ (1), Jehovah’s Witness (1),
and no religious affiliation (1). The religious affiliation of the ministers included African
Methodist Episcopal Zion-AME (1), Episcopal (1), nondenominational (1), and Presbyterian (2).
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Polzer and Miles found there were three main typologies in their study participants
regarding spirituality and diabetes management: God is in the background, God is in the
forefront, and God is healer. The study participants who saw God as in the background felt that
God was always present with them but that it was their responsibility to participate in their
relationship with God. This participation included performing diabetes self-management
activities, spiritual activities, and having faith that God would provide them with the support they
needed to manage their diabetes. Members of this typology acknowledged that they were
responsible for their diabetes and God was a supportive force there to assist them. This typology
contained five study participants and three ministers, all of the Episcopal faith.
Those who saw God at the forefront of their diabetes management also participated in a
relationship with God by performing self-care behaviors, spiritual practices, and having faith;
however, these participants viewed God's role in their diabetes management as more important
than their own role. These participants felt that, if they had enough faith and submitted
themselves to the authority of God, their diabetes would be healed and God would take care of
them. A total of 22 participants were in this typology (16 women and 6 men). The religious
affiliation of this group included Apostolic, Baptist, Church of God, Holiness, Methodist,
nondenominational, Resurrection, and Power of Jesus Christ. One AME Zion minister belonged
to this typology as well.
Those who saw God as Healer also managed their diabetes through a relationship with
God and believed that, if they had enough faith, God would heal them; however, they believed
that, if they were spiritually mature enough and had enough faith, they did not need to manage
their diabetes. One male participant and one minister belonged to this typology, both identifying
as nondenominational. A 53-year-old Jehovah’s Witness man did not fall into any of the
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abovementioned typologies and managed his diabetes due to his hope for and belief in the
afterlife. Faith and religious beliefs play a major role in the African-American community, and
healthcare providers need to consider this when educating this patient population on chronic
disease management. Another consideration that healthcare providers should keep in mind is the
dietary habits of African Americans.
Dietary Habits of African Americans
Historically, the diets of African Americans have differed from the diets of other ethnic
groups. These differences may have contributed to African Americans having higher rates of
chronic diseases such as hypertension or diabetes. African Americans typically consume diets
that are high in fat, calories, and salt, as well as salt-cured, smoked and nitrite-cured foods, and
that are low in fruits, vegetables, and whole grains. Diet plays a major part in managing diabetes;
therefore poor eating habits put many African Americans with diabetes at risk of having poor
glycemic control (Bovell-Benjamin, Dawkin, Pace, & Shikany, 2009).
When slaves were brought to the US, they combined their cooking methods with those of
the British, Spanish, and Native Americans to develop what is now known as soul food. Soul
food places emphasis on foods that are fried, roasted, or boiled and are usually made of chicken,
pork, pork fat, or organ meat, as well as sweet potatoes, corn, and green leafy vegetables. James
(2004) explored the factors that influence the food choices of African Americans and the
attitudes that African Americans have towards nutrition. This study conducted six focus groups
in north central Florida. The focus groups consisted of 40 participants (19 women and 21 men)
who answered questions about the following topics: concepts of healthy eating, barriers and
motivators to healthful eating.
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This study revealed that women in the African-American community would be more
willing than the men to make healthy lifestyle changes. The participants felt that women were the
best targets for nutritional education because they do the shopping and prepare the food and that
the men studied were not interested in changing to healthy eating habits. Another important
factor noted in this study is that nutritional education in the African-American community should
go beyond the individual and should target immediate and extended family as well.
Lucan, Barg, and Long (2010) explored barriers to healthy eating in low-income African
Americans in Philadelphia. Forty participants (20 men and 20 women) were interviewed for this
study. Results showed that the flavor of food prompted the consumption of all foods. The
participants also mentioned the cost of healthy foods as a barrier, as well as location and
convenience.
Evidence Supporting Diabetes Education and Lifestyle Modifications
Research has shown that diabetes education and lifestyle modifications help reduce the
incidence of diabetes and help to delay or prevent complications related to diabetes. Several
studies have explored ways to provide diabetes education and lifestyle modifications to African
Americans; however, not one specific study could be found that posits a clear-cut way to reach
this population that has made significant changes in the rate or complications of diabetes in
African Americans.
Anderson-Loftin et al. (2005) examined the effect a culturally sensitive dietary and self-
management intervention had on physiological outcomes and food behaviors of African
Americans with diabetes. A total of 97 participants with high-risk diabetes in rural South
Carolina were studied. They were defined as high risk due to one of the following: a
glycosylated hemoglobin (HgA1c) greater or equal to 8%; cholesterol greater than or equal to
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200; triglycerides greater than or equal to 200; LDL cholesterol greater than or equal to 100; and
weight greater than or equal to 25kg/m; or high dietary fat patterns all determined by the
participant’s score on a food habits questionnaire.
The groups were split in half, with 49 in the experimental group and 48 in the control
(usual care) group. Participants in the experimental group were instructed on how to make
healthy low-fat food choices as well as on purchasing, planning, and preparing low-fat healthy
meals, and food choices away from home. The researchers used ethnic food models to teach the
participants how to prepare healthy meals as well as in-class cooking demonstrations. The
control group participants were referred to a local, traditional diabetes class where they were
given information regarding diabetes and the complications of diabetes. Data on both the
experimental and control groups were collected at baseline, 6 months, and at the end of the
intervention. At 6 months, members of the experimental group decreased their weight by 1.8 kg
(4 lbs), while the weight of individuals in the control group increased 1.9 kg (4.2 lbs). There
were no significant differences in the HgA1c values between the two groups.
Leeman, Skelly, Burns, Carlson, and Soward (2008) conducted a pilot study in which
they tailored a diabetes management intervention to 43 older, rural African-American women.
An intervention that was focused on the symptoms of diabetes as well as self-care practices was
administered to the participants. The women were randomly assigned to an intervention group
and a comparison group. The participants were questioned about their symptom experiences, the
strategies they used to manage their symptoms, and how they managed their diabetes. The
information obtained allowed the research nurse to develop individualized interventions that
focused on each participant’s past symptom experience. The participant’s symptomatology was
used as a guide for subsequent visits with the research nurse; this approach differed from
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traditional diabetes education. At the conclusion of this pilot study, the researchers found that the
intervention group showed more improvement when compared to the control group in
recognizing their symptoms, in their diabetes self-care practices, and in their quality of life.
Evidence Supporting Culturally Sensitive Diabetes Education in African Americans
Steinhardt, Mamerow, Brown, and Jolly (2009) examined the effectiveness of the
Diabetes Coaching Program (DCP) intervention that was adapted for African Americans. This
pilot study contained a convenience sample of 16 African Americans (8 men, 8 women) who
were recruited via radio and announcements in local churches. Quantitative data were collected
pre-intervention and at 6 months, while qualitative data were collected at 8 months.
The DCP intervention consisted of four 2-hour weekly classes; these classes focused on
the Transforming Lives through Resilience Education and nutrition in diabetes. In addition to
these meetings, eight biweekly support group meetings were held. The Transforming Lives
through Resilience Education portion of the intervention was intended to equip the participants
with the necessary skills to cope effectively with the stressors of having diabetes, to begin to feel
empowered about managing their diabetes, and to assist with developing meaningful social
connections with others who have diabetes. The nutritional portion of the intervention provided
participants with the information, skills, and support needed for better diabetes management. The
researchers found that, prior to the beginning of the study, the mean baseline HgA1c for the
participants was 6.94 and that, following the intervention, the mean HgA1c was 5.57. Qualitative
information was gathered on the participants at 8 months to ascertain if they felt the DCP
intervention was effective, and 11 of the 12 participants who participated in the 8-month-follow-
up indicated they felt the intervention was effective.
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Utz et al. (2008) conducted a pilot study to evaluate a culturally tailored intervention for
rural African Americans. The study was conducted over 6 months and took place at a local
community center in the participants’ community.
Participants of this study were randomly selected to take part in a group or an individual
Diabetes Self Management Education (DSME) program. The purpose of the DSME program is
to equip participants with the needed skills to manage their diabetes effectively. Study
participants who received the group DSME met for 2 hours weekly for a total of 8 weeks. The
DSME group activities consisted of storytelling, hands-on activities, and problem-solving
activities. While those assigned to the individual DSME met with a certified diabetes educator on
three different occasions over an 8-week period, and worked on individual goal-setting as well as
problem-solving strategies for diabetes management. All received culturally tailored information
based upon seven areas of diabetes self-management that included healthy eating, being active,
monitoring blood glucose, taking medication, problem-solving, reducing risks, and healthy
coping. Participants in both groups lowered their HgA1c; however, participants in the group
DSME lowered theirs more than the individual DSME (Group DSME = -.32, individual DSME
= -.24). Participants in the group DSME showed greater improvement in the diabetes self-care
activities, which included self-management skills related to general diet, specific diet, exercise,
blood glucose monitoring, foot care, and smoking. The Group DSME members improved their
carbohydrate spacing when compared to member of the individual DSME intervention.
Cramer, Sibley, Bartlett, Kahn, and Loffredo (2007) examined the effectiveness of the
Diabetes Prevention Program Lifestyle Resources Core Teaching Plan in African Americans
with diabetes. This pilot study examined the effectiveness of a culturally tailored, edited version
of the Diabetes Prevention Program (DPP) for managing underserved urban African Americans
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with diabetes. The researchers incorporated the DPP teaching plan as well as an evidence-based,
accelerated, medical management algorithm. The study took place over 9 months and differed
from the original DPP in that it was implemented in patients with diabetes. A total of 67
participants were recruited from family medicine clinics that served predominantly minority
patients who lived in the inner city of Buffalo, NY. The study participants were randomly placed
in either the nurse case management intervention or the usual care intervention.
The original DPP curriculum consisted of 16 modules that were implemented over a 24-
week period with monthly follow-up appointments during the remainder of the study; this was
not feasible in the study of Cramer et al., and the study content was therefore edited. The edited
version of the DPP consisted of seven modules that focused on basic diabetes knowledge,
complications of diabetes, individual diet and exercise goals, basic education on the caloric and
fat content of foods, guidance in selecting appropriate exercise and physical activity for age and
physical condition, specific strategies for eating out, diabetes self-monitoring techniques, dietary
and exercise relapse prevention, and individual coaching.
The authors found the DPP intervention group had better outcomes than the usual care
intervention group. Participants in the DPP group increased their walking by an average of 34–
54 minutes per week, while the usual care group decreased their walking by 19 minutes per
week. The absolute HgA1c percentage fell an average of 1.87 in the intervention group and 0.54
in the usual care group. This study was successful in achieving weight loss and positive dietary
changes in high-risk diabetic African-American patients. The participants also responded
positively to the culturally relevant dietary portion of the classes as well as the face-to-face case
management.
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Synthesis
The studies cited indicate that, even with the wealth of knowledge available on diabetes
management and the complications of untreated or undertreated diabetes, a knowledge deficit
continues in the African-American community. This community has a disproportionate rate of
diabetes when compared to other ethnic groups. The reasons for the high rate of diabetes in
African Americans is not fully understood; however, studies have shown that one major reason is
lack of knowledge and understanding with regard to the disease sequelae and the consequences
of untreated or undertreated diabetes, as well as possessing a fatalistic attitude and the diabetic’s
spiritual beliefs. Providing education alone to this patient population has not been shown to be
effective in decreasing the rate of diabetes and its complications. Healthcare providers who are
educating African Americans on diabetes should take into consideration the patient’s beliefs
regarding diabetes, consider the role religion plays in those views, and provide culturally
relevant and sensitive materials to the patient.
Health Belief Model
The Health Belief Model was originally developed by Irwin Rosenstock to try to
understand why individuals did not perform preventative healthcare measures (Carpenter, 2010).
The Health Belief Model is patient-centered and focuses on behavior modification. It postulates
that an individual’s perception of five different variables can help predict his or her healthcare
behavior. The first variable is perceived risk or susceptibility to a health problem. The model
argues that individuals will become motivated to adopt healthy behaviors if they believe they are
susceptible to a negative health outcome. The second variable is the perceived severity of a
negative health outcome. The model argues that the stronger the perception an individual has
regarding the possibility of developing a negative health outcome, the more likely he or she is to
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avoid behaviors that will cause that outcome. Perceived benefits, the third variable, affect
healthcare behaviors because the individual is more likely to adopt healthy behavior if he or she
perceives a benefit to doing so. Barriers to adopting healthy behaviors represent the fourth
variable. The model argues that the more barriers individuals believe they will face in adopting
healthy behaviors, the less likely they are to change their behavior. Finally, this model postulates
that there are internal and external cues to action that either help or prevent individuals from
changing their health behavior (Carpenter, 2010; Harvey & Lawson, 2008).
This model formed the basis for this DNP scholarly project. The educational materials
were presented in such a way that the participants understood their susceptibility of either
developing diabetes or the complications of diabetes. The severity of the disease was discussed
with the participants as well as the benefits and barriers to developing a more healthy lifestyle.
Figure. Rosenstock’s Health Belief Model
Indian Journal of Public Health 56(3) 184
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Project Description
Description of Group, Community, Population, and Results of Needs Assessment
The DNP scholarly project was provided to African-American patients who received
their primary healthcare at Mary Mahoney Health Center in Spencer, Oklahoma. Inclusion
criteria to participate in the project consisted of the following: male or female African American,
age 30–65; having been diagnosed with diabetes; or having a family member who has been
diagnosed with diabetes.
Spencer, Oklahoma is part of the Oklahoma City metropolitan area; however, it is a rural
community. The population in 2010 was approximately 4,000, with the median household
income being approximately $34,000. Approximately 56% of the population in Spencer is
African American, 29% is Caucasian, and the remainder consists of Asian Americans, Hispanic
Americans, and Native Americans.
Mary Mahoney Health Center has been open since 1973 and is a private, nonprofit
primary healthcare facility. It provides healthcare and dental services, as well as lab and
radiology services to its healthcare consumers. Healthcare is provided to individuals with and
without insurance, and fees are based upon family size and income. The facility has three full-
time physicians, four full-time nurse practitioners, and medical assistants, as well as a counselor
and dental staff.
A discussion was held in April 2012 with the medical director regarding quality
improvement projects and improving patient healthcare outcomes in. One of the major healthcare
problems faced by the patient population is uncontrolled diabetes, as well as complications from
uncontrolled diabetes. The medical director noted that the patients at the clinic have knowledge
deficits regarding diabetes and that a comprehensive diabetes education program would be
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beneficial. The clinic had a diabetes education program; however, attendance had been low, and
the class currently offered is geared only toward patients who are on insulin therapy. The clinical
site was looking for new ways to engage all diabetic patients and improve their health outcomes.
The key stakeholders of the DNP scholarly project included the medical director, the CEO, the
clinic dietician, as well as the patients themselves. This DNP candidate worked closely with
these stakeholders during the implementation of the project.
Description of Resources, Constraints, and Facilitators or Barriers to Implementation
The diabetes education program selected by the DNP(c) was the Road to Health Diabetes
Education program (Road to Health Toolkit, 2009). This program was developed by the National
Diabetes Education Program in partnership with the National Institutes of Health and the Centers
for Disease Control and Prevention. The program was designed specifically to prevent or delay
the development of diabetes or diabetes complications in the African-American and Latino
communities. The DNP(c) used educational materials from the Road to Health program as a
foundation and adapted the program to meet the needs of the participants attending the DNP
scholarly project at Mary Mahoney Health Center.
The DNP scholarly project was implemented at Mary Mahoney Health Center and took
place in the education room. Some available resources used to assist in implementation of this
project included usage of the education room, teaching aids, diabetes hand-outs, and access to
the electronic medical records of participants to obtain their HgA1c values. One major barrier to
the implementation of the DNP scholarly project that the DNP(c) tried to overcome was lack of
interest from the target population and the fatalistic attitude of the providers in the clinic.
Possible ways to increase interest that were used included providing snacks at the education
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sessions, giving away free resources such as diabetic cookbooks, glucometers, test strips, and
other diabetes resources.
Protocol/Plan
The DNP scholarly project was implemented over a 5-week period and consisted of
weekly sessions that lasted approximately 2 hours. Participants were recruited by flyers that were
placed in exam rooms and in high-traffic areas of the clinic. Patients were also referred to the
program by providers in the clinic. The Road to Health program had three different sections,
each section containing four separate units. The DNP(c) selected those topics that were most
relevant to the specific patient population at Mary Mahoney Health Center, and those topics were
covered in the DNP scholarly project. The HgA1c of the participants who had been diagnosed
with diabetes were evaluated at the beginning of the program; however, those in attendance for
family members did not have this done. IRB approval was not needed for this DNP scholarly
project. The project started at the end of February 2013 and lasted for 5 weeks. At the end of the
project, the HgA1c values of the participants were again evaluated to determine if there was any
change. Participants were also given a pre- and post-test (Appendix A) to evaluate their
knowledge base before implementation of the program and afterwards. They were also given an
evaluation form (Appendix B) upon which they were asked to assess the program.
Goals and Objectives
The goal of this project was to have 10 participants attend the educational sessions each
week with an expected outcome of 5 participants actually showing up for each weekly session.
The DNP(c) also set a goal that each participant would have a 1-point decrease in his/her HgA1c
at the conclusion of the DNP scholarly project. The goal of increased knowledge was to have a
30% increase when the pre-test and post-test scores were compared. Another goal set forth by the
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DNP(c) was to provide the participants with culturally relevant information about diabetes and
their risk of either developing diabetes or experiencing its complications. The DNP(c) hoped to
dispel some of the myths about diabetes in the African-American population by providing solid
information that would assist them in managing their diabetes, improving their glycemic control,
and bettering their own and their family’s health outcomes.
Costs
Attendance at the DNP scholarly project was free to clinic participants and their family
members; however, copies of each week’s educational materials were made to hand out to the
participants. The Road to Health participant booklet consists of 76 pages, and it cost
approximately $38 to copy the entire booklet. The DNP(c) used the information provided in the
Road to Health Diabetes Education program as well as information from research journals,
online websites, textbooks, and diabetes books to develop Powerpoint presentations each week
for the class participants. Once the Powerpoint presentations were completed, they were taken to
a local print shop and 10 copies were made each week. The total cost for the entire 5-week
program was approximately $250. Along with the printed copies, the DNP(c) also gave each
participant a recyclable bag that contained a notebook for storing the printed materials, a
resuable water bottle, an ink pen, and a small notebook in which participants could record their
blood sugars. The total cost for these bags was approximately $50. The remainder of the cost for
this DNP scholarly project was devoted to providing the class participants with prizes and
incentives as follows: cookbooks, snacks, Subway gift cards, food scale, hand weights,
pedometers, measuring cups, measuring spoons, and, a kit that included a glucometer, strips,
alcohol wipes, and lancets. The total cost for these materials was approximately $300. The total
cost of implementing this DNP scholary project was approximately $600 (Appendix C).
22
Results, Data Analysis, and Interpretation
Prior to the implementation of this DNP scholarly project, the DNP(c) met with the
medical director of the clinic again to discuss strategies to recruit and retain participants for the
education program. The DNP(c) was informed that the various healthcare providers in the clinic
would refer their patients and that two community volunteers would be contacting potential
participants via telephone. The DNP(c) also developed flyers advertising the date and time of the
classes and placed them in high-traffic areas of the clinic and provided all providers with the
flyers to hand out to their patients. Prior to implementation of the program, the DNP(c) also
personally invited all African-American diabetic patients whom she encountered during her
clinical hours to attend the classes. The Road to Health Diabetes education program is intended
to be taught during a full one-day session; however, the DNP(c) chose to adapt the program to
the audience and to break it down into weekly sessions and also to add information to the basic
information the program provided. Initially, the DNP(c) had planned to teach an 8-week
program; however, this was reduced to 5 weeks due to low participation rates and the candidate
being able to cover the material in a shorter time frame.
Population Results
Initially, the DNP(c) had to conduct one-on-one educational classes for the first 2 weeks
of the program. This was done for two separate reasons: (a) no participants showed up at the
scheduled time or place for the first classes, and (b) this was an opportunity to develop a personal
connection and rapport with potential project participants. Therefore, the candidate taught each
participant individually when requested by her preceptor or other clinic providers. Each
participant was given a bag that contained a notebook with a folder containing educational
materials to be covered during the educational session. A total of six participants received
23
individual diabetes education during the first 2 weeks of the program (a total of five the first
week, and one the second week). Each of these participants was contacted by the DNP(c) and
community volunteers and was asked to attend the next week’s class; however, none of those
taught individually the first 2 weeks returned to any subsequent classes.
During the third week of the DNP scholarly program, two participants showed up at the
scheduled time and place for the class. Those participants had been contacted by the community
volunteers and agreed to participate in the class. During this class, the DNP(c) taught the
information that had been covered during the first 2 weeks as well as the material to be covered
during the third week. Both participants were encouraged and invited to return to class the
following week, which they did. During the fourth week of class, the two participants from the
prior week returned, as well as two others. The DNP(c) covered the information from the prior 3
weeks with those new participants, as well as the current week’s information. The last week of
the diabetes education class was attended by three participants: two who had participated in the
classes the prior 3 weeks, and another participant.
Class Structure
Each week, except for the week when medications were covered, participants were given
a pre-test to examine their knowledge level of the information being covered and a post-test,
which was the same as the pre-test (Appendix A). They were also given a notebook and handouts
that covered that week’s lesson. Each week, games were played with the participants such as
diabetes word find, diabetes word search, and diabetes bingo. Each week, the participants were
given new information. Topics covered included the basics of diabetes, complications of
diabetes, carbohydrate counting, diabetic medications, and healthy eating, and exercise. Winners
of the games that were played each week were given prizes that coordinated with the lesson
24
being taught that week. Participants were also given an anonymous evaluation form that they
were asked to complete; this form helped the candidate to determine which aspects of the class
the participants enjoyed and which they did not enjoy.
Follow-up Phone Calls
The community volunteers were an integral part of recruiting and retaining class
participants. Each week, the community volunteers were given the name and phone number of
that week’s participants, whom they would contact. They also contacted other African-American
patients in the clinic with uncontrolled diabetes who would benefit from the class. Potential
participants were also offered free transportation to and from the classes, and the community
volunteers also provided information about needed resources such as help with medications and
help scheduling follow-up appointments with providers.
Patient Outcomes
The EMR of each participant was reviewed to determine his or her baseline HgA1c, but
because, only two participants returned for more than one class, their HgA1c was noted at
baseline and at the end of the DNP scholary project. Both return participants showed
improvement in their HgA1c values at the end of their participantion in the class (see Table 1).
Table 1
Pre- and Post-HgA1c Values
Participant Date Attended Class Return to Class? HgA1c
#1 02/25/13 No Pre-class 7.1
#2 02/25/13 No Pre-class 6.4
#3 02/25/13 No Pre-class 10.8
25
#4 02/25/13 No Pre-class 14.0
#5 02/25/13 No Pre-class 10.3
#6 03/04/13 No Pre-class 8.5
#7 03/11/13 No Pre-class 6.3
#8 03/11/13, 03/18/13,
03/25/13
Yes Pre-class 12.3
Post-class 10.3
#9 03/11/13, 03/18/13,
03/25/13
Yes Pre-class 11.4
Post-class 11.2
#10 03/18/13 No Pre-class 14.0
#11 03/18/13 No Pre-class 9.4
#12 03/25/13 No Pre-class 6.5
The HgA1c range among participants was 6.4–14.0. As Table 1, above, indicates, the
majority of the class participants had uncontrolled diabetes and would have benefited greatly if
they had returned to the class. However, there were also participants who had controlled
diabetes, and those participants picked which classes they attended based upon the information
that was being taught each week. Both return participants had an improvement in the HgA1c at
the end of the classes; however, only one met the HgA1c goal the candidate was trying to
achieve by implementing this DNP scholary project. The average pre-test score for the
participants of this project was 40–50%; however, the average post-test score was 80–100%.
That is an increase of 40–50%, which surpassed the DNP(c)’s education goal of the participants
increasing their post-test scores by 30%.
26
Participant Satisfaction
Each week, the participants were given an evaluation form to complete anonymously
after the class; the only negative feedback was that the participants would have enjoyed the class
more if there had been more participants. The participants enjoyed the subjects covered and
expressed that they learned something new each week, that they enjoyed the games that were
played, and that they felt they now had tools to help them better manage their diabetes.
Barriers to the Program
Participant Barriers
There are many factors that this DNP(c) viewed as barriers to patient participation in the
diabetes education program. Nam, Chesla, Stotts, Kroon, and Janson (2011) reviewed previous
studies to examine barriers to diabetes management from both the patient and provider point of
view. They noted that patient attitudes regarding the need for improved glycemic control has an
impact if a patient is interested in participating in diabetes education. They also found similar
attitudes toward adherence to prescribed medications: If those studied felt their prescribed
medications would benefit their diabetes, they were more likely to adhere to their medication
regimen. The researchers found also that, even though knowledge was an important part of
diabetes management, knowledge was not the most important factor in improving diabetes self-
care behaviors in the study participants. Cultural factors also played a major role in improved
diabetes management: They found that the deep spiritual roots possessed by many African
Americans may help to improve their diabetes management.
This DNP(c) did notice different attitudes among those participants who came once to the
class and the two participants who returned for the final three sessions. The two participants who
returned for those three sessions were more engaged during the classes, more vocal, and they
27
participated more. They also voiced weekly that they wanted to improve their health outcomes,
while those who did not return were less engaged during the educational sessions and appeared
less concerned about their diabetes management, or said that they had too many other things
going on in their lives to return for classes. Other factors that may have played a part in the low
participation rate included the following: (a) initial concerns about transportation back and forth
to classes, although that concern was alleviated by offering transportation to those who did not
have it, (b) concerns about missing work, (c) lack of interest in the class, and (d) personal issues
that took the patient’s focus away from improving their healthcare. Another factor that may have
played an important role in the low class-participation rate is the relationship the patient had with
his or her healthcare provider and the healthcare provider’s attitude.
Healthcare Provider Barriers
This DNP(c) did not expect a negative attitude among the healthcare providers at the site
of the DNP scholary project; however, she heard on more than one occasion and from more than
one provider that “our patients just don’t participate in health education programs.” This
statement both confused and propelled her to prove them wrong and, although the candidate did
not have a large number of participants, she was able to get two participants to return for 3
consecutive weeks. Doing this caused her to wonder why she had achieved success (small, yet
success nonetheless), while the providers at the clinic repeatedly said their patient population
would not attend any type of educational session.
Nam et al. (2011) proposed that a healthcare provider’s attitude toward diabetes
management may be more important than the knowledge the provider has about diabetes. They
also noted that the attitude of the healthcare provider influences the patient’s level of adherence
to their treatment regimen. During an encounter with a healthcare provider, if the patient can
28
sense the frustration the provider feels toward the patient and his/her poor management of the
disease, the patient may begin to feel that neither he/she nor the provider can control the
diabetes, thus diminishing the patient’s ability to feel empowered and able to manage his/her
diabetes. This DNP(c) wonders if patients who are seen at this clinical site can sense the
frustration or lack of trust regarding their ability to manage their diabetes from their healthcare
provider and if this affects their outcomes. The patient-provider relationship and ability to
communicate effectively also influence patient outcomes, as does a collaborative relationship
between patient and provider. Heisler et al. (2003) noted that patients who agreed with their
providers regarding treatment regimens were more likely to adhere to treatment
recommendations and rated their ability to manage their diabetes as higher than those who did
not agree with their providers.
Limitations
The biggest limitation to this project was patient participation. Although participants
were offered free transportation, free class materials, and incentives such as prizes for winning
games or participating in class, the participation level was still low. The HgA1c of the majority
of the participants was out of control, and this candidate is not sure if this is a good
representation of the majority of the African-American patients with diabetes who receive care at
the facility. However, the majority of diabetic patients the DNP(c) encountered during her
clinical time at this facility would lead her to believe that participants in the DNP scholarly
project were a good representation of African-American patients with diabetes at the facility.
Conclusion
Diabetes is a major health problem in the US; it affects individuals of all economic
statuses as well as all ethnic groups. However, African Americans with diabetes encounter more
29
severe complications from diabetes when compared with other ethnic groups. Evidence suggests
that tight glycemic control and increased knowledge about diabetes and the consequences of
poor glycemic control may help to improve their diabetes outcomes. In the patients who attended
more than one educational session, improvement in their HgA1c was noted. This DNP(c) does
believe that a diabetes education program can be successfully implemented at Mary Mahoney
Health Center; however, the attitudes of both the patients and the providers will have to improve
in order for the program to be successful. Incentives and giveaways seemed to help motivate the
two return participants, and the DNP(c) believes that the use of monetary incentives may help
promote more individuals to attend classes on a routine basis. The site where the DNP scholary
project was implemented is currently in the process of writing a grant for the implementation of
another diabetes education program in the future. This program will utilize its funds to engage
various speakers such as cardiologists, podiatrists, dieticians, and chefs to discuss different topics
with participants. Funds will also be used to provide participants with written materials and
cookbooks. Though the numbers were small, this DNP scholarly project did show that increasing
the knowledge of African Americans with diabetes can help improve glycemic control and
therefore improve their diabetes outcomes.
30
References
American Diabetes Association. (2011a). Diabetes Statistics. Retrieved from
http://www.diabetes.org/diabetes-basics/diabetes-stastics
American Diabetes Association. (2011b). Living with diabetes—African Americans and
complications. Retrieved from http://www.diabetes.org/living-with-
diabetes/complications/african-americans-and-complications.html
Anderson-Loftin, W., Barnett, S., Bunn, P., Sullivan, P., Hussey, J., & Tavakoli, A. (2005). Soul
food light: Culturally competent diabetes education. The Diabetes Educator, 31(4), 555–
563.
Bovell-Benjamin, A., Dawkin, N., Pace, R., & Shikany, J. (2009). Use of focus groups to
understand African-Americans' dietary practices: Implications for modifying a food
frequency questionnaire. Preventive Medicine, 48, 549–554.
Calvin, D., Quinn, L., Dancy, B., Park, C., Fleming, S., Smith, E., & Fogelfeld, L. (2011).
African American's perception of risk for diabetes complications. The Diabetes Educator,
37(5), 689–698.
Carpenter, C. (2010). A meta-analysis of the effectiveness of health belief model variables in
predicting behavior. Health Communication, 25, 661–669.
Centers for Disease Control and Prevention. (2011). 2011 National Diabetes Fact Sheet.
Retrieved from http://www.cdc.gov/diabetes/pubs/estimates11.htm
Cramer, J., Sibley, R., Bartlett, D., Kahn, L., & Loffredo, L. (2007). An adaptation of the
diabetes prevention program for use with high-risk, minority patients with type 2
diabetes. The Diabetes Educator, 33(3), 503–508.
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Cullen, K., & Buzek, B. (2009). Knowledge about type 2 diabetes risk and prevention of
African-Americans and Hispanic adults and adolescents with family history of type 2
diabetes. The Diabetes Educator, 35(5), 836–842.
Egede, L., & Bonadonna, R. (2003). Diabetes self-management in African Americans: An
exploration of the role of fatalism. The Diabetes Educator, 29(1), 105–114.
Harvey, J., & Lawson, V. (2008). The importance of health belief models in determining self-
care behavior in diabetes. Diabetic Medicine, 26, 5–13.
Heisler, M., Vijan, S., Anderson, R., Ubel, P., Bernstein, S., & Hofer, T. (2003). When do
patients and their physicians agree on diabetes treatment goals and strategies, and what
difference does it make. Journal of General Internal Medicine, 18, 893–902.
James, D. (2004). Factors influencing food choices, dietary intake, and nutrition-related attitudes
among African Americans: Application of a culturally sensitive model. Ethnicity &
Health, 9(4), 349–367.
Leeman, J., Skelly, A., Burns, D., Carlson, J., & Soward, A. (2008). Tailoring a diabetes self-
care intervention for use with older, rural African American women. The Diabetes
Educator, 34(2), 310–317.
Lucan, S., Barg, F., & Long, J. (2010). Promoters and barriers to fruit, vegetable and fast-food
consumption among urban, low-income African Americans—A qualitative approach.
American Journal of Public Health, (4), 631–634.
Mann, D., Leventhal, H., Ponieman, D., & Halm, E. (2009). Misconceptions about diabetes and
its management among low-income minorities with diabetes. Diabetes Care, 32(4), 591–
593.
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McKenzie, C., & Skelly, A. (2010). Perceptions of coronary heart disease risk in African
American women with type 2 diabetes: A qualitative study. The Diabetes Educator, 36(5)
766–773.
Nam, S., Chesla, C., Stotts, N., Kroon, L, & Janson, S. (2011). Barriers to management: patient
and provider factors. Diabetes Research and Clinical Practice, 93, 1–9.
Office of Minority Health. (2012). Diabetes and African Americans. Retrieved from
http://www.minorityhealth.hhs.gov.
Polzer, R., & Miles, M. (2007). Spirituality in African Americans with diabetes: Self-
management through a relationship with God. Qualitative Health Researth, 17(2), 176–
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Skelly, A., Dougherty, M., Gesler, W., Soward, A., Burns, D., & Arcury, T. (2006). African
American beliefts about diabetes. Western Journal of Nursing Research, 28(1), 9–28.
Steinhardt, M., Mamerow, M., Brown, S., & Jolly, C. (2009). A resilience intervention in
African American adults with type 2 diabetes: A pilot study of efficacy. The Diabetes
Educator, 35(2), 274–284.
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Culturally tailored intervention for rural African Americans with type 2 diabetes. The
Diabetes Educator, 34(5), 854–865.
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Effect of diabetes fatalism on medication adherence and self-care behaviors in adults with
diabetes. General Hospital Psychiatry, 34, 598–603.
33
Wenzel, J., Utz, S., Steeves, R., Hinton, I., & Jones, R. (2005). Plenty of sickness: Descriptions
by African Americans living in rural areas with type 2 diabetes. The Diabetes Educator,
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http://www.womenshealth.gov/minority-health/african-americans.
34
Appendix A
Road to Health Pre-Test #1
Name:________________________ Date: _________________
1. Which ethnic group had the highest rate of diabetes between 2007 and 2009?
A. Caucasians
B. Asians
C. African Americans
D. Hispanics
2. More people die from cancer than diabetes each year
A. True
B. False
3. What causes diabetes?
A. Eating too much sugar
B. Family History
C. Being Overweight
D. A&B
E. B&C
4. Insulin is made in which body organ?
A. Stomach
B. Kidneys
C. Pancreas
D. Liver
5. Which of the following are signs of diabetes?
A. Frequent thirst
B. Falling down a lot
C. Frequent cough
D. Bleeding easily
6. Which of the following are risk factors for developing Diabetes
A. Being overweight
B. Drinking soda
C. Family History
D. A&B
E. A&C
7. Nothing can be done to prevent diabetes
A. True
B. False
8. If you have a family history of diabetes you will definitely develop diabetes
A. True
B. False
35
Road to Health Pre-Test #2
Name:__________________________ Date:____________________
1. Kidney disease is the # 1 case of death or disability in individuals with Type 2 Diabetes?
A. True
B. False
2. What percentage of Type 2 Diabetes die from some form of heart disease or stroke
A. 10%
B. 65%
C. 50%
D. 90%
3. A Heart attack occurs when the heart can’t pump enough blood to meet the body’s needs
A. True
B. False
4. What level do you want your HgA1c (3 month blood sugar)
A. 8 or above
B. 7 or less
C. 10 or above
D. 9 or less
5. How often should an individual with Type 2 diabetes get their eyes check?
A. Once every 6 months
B. Every 2 years
C. Once a year
D. Every 3 months
6. Coronary Heart Disease occurs when plaque builds up in the coronary arteries
A. True
B. False
7. What level should an individual with Type 2 Diabetes try to keep their blood pressure?
A. 140/90
B. 130/80
C. 100/60
D. 160/100
36
Road to Health Pre-Test #3
Name:__________________________ Date:____________________
1. Diabetics should never eat carbohydrates?
A. True
B. False
2. Carbohydrates are found in meats and fish?
A. True
B. False
3. Which of the following are starchy vegetables
A. Broccoli
B. Tomatoes
C. Sweet Onions
D. Green Peas
4. 1 Carb Choice is equal to 30 grams of Carbohydrates?
A. True
B. False
5. To Maintain their weight women should eat 30-45 carbohydrates per meal?
A. True
B. False
6. To lose weight men should eat 45-60 carbohydrates per meal
A. True
B. False
7. Your fist is about the size of 3 ounces?
A. True
B. False
8. Your thumb equals about 1 ounce
A. True
B. False
37
Road to Health Pre-Test #4
Name:____________________ Date: _________________
1. The American Diabetes Association has a specific diet they recommend diabetics to
follow?
A. True
B. False
2. How many servings of milk or dairy products should you eat each day?
A. 0
B. 1-2
C. 2-3
D. 3-4
3. Which of the following is the best oils to cook with?
A. Canola
B. Coconut
C. Peanut
D. Lard
4. Which if the following are benefits of exercising?
A. It helps to lower your blood pressure
B. It helps you lose weight
C. It helps to lower blood glucose levels
D. All of the above
5. What is the first thing you should do before starting an exercise plan?
A. Start slow
B. Make a plan
C. Discuss with your healthcare provider
D. Find an exercise activity you like
6. How much exercise should you complete each week
A. 1 hour most days of the week
B. 10 minutes most days of the week
C. 30 minutes most days of the week
D. 45 minutes most days of the week
7. Walking slowly for 30 minutes you can burn about 105 calories?
A. True
B. False
8. Aerobic Exercise helps you to build strong bones and muscles?
A. True
B. False
38
Road to Health Pre-Test #5
Final Test
Name:____________________ Date: _________________
1. Which ethnic group had the highest rate of diabetes between 2007 and 2009?
A. Caucasians
B. Asians
C. African Americans
D. Hispanics
2. Insulin is made in which body organ?
A. Stomach
B. Kidneys
C. Pancreas
D. Liver
3. Which of the following are signs of diabetes?
A. Frequent thirst
B. Falling down a lot
C. Frequent cough
D. Bleeding easily
4. Nothing can be done to prevent diabetes
A. True
B. False
5. Kidney disease is the # 1 case of death or disability in individuals with Type 2 Diabetes?
A. True
B. False
6. What level do you want you HgA1c (3 month blood sugar)
A. 8 or above
B. 7 or less
C. 10 or above
D. 9 or less
7. How often should an individual with Type 2 diabetes get their eyes check?
A. Once every 6 months
B. Every 2 years
C. Once a year
D. Every 3 months
39
8. What level should an individual with Type 2 Diabetes try to keep their blood pressure?
A. 140/90
B. 130/80
C. 100/60
D. 160/100
9. Carbohydrates are found in meats and fish?
A. True
B. False
10. Which of the following are starchy vegetables
A. Broccoli
B. Tomatoes
C. Sweet Onions
D. Green Peas
11. Carb Choice is equal to 30 grams of Carbohydrates?
A. True
B. False
12. Your fist is about the size of 3 ounces?
A. True
B. False
13. The American Diabetes Association has a specific diet they recommend diabetics to
follow?
A. True
B. False
14. Which of the following is the best oils to cook with?
A. Canola
B. Coconut
C. Peanut
D. Lard
15. Which if the following are benefits of excercising?
A. It helps to lower your blood pressure
B. It helps you lose weight
C. It helps to lower blood glucose levels
D. All of the above
16. How much exercise should you complete each week
A. 1 hour most days of the week
B. 10 minutes most days of the week
C. 30 minutes most days of the week
D. 45 minutes most days of the week
17. Once you are diagnosed with Diabetes and your A1c is less than 7.5 you are
automatically placed on medication
40
A. True
B. False
18. Glipizide works by causing the pancreas to decrease the amount of insulin the body
makes?
A. True
B. False
19. Metformin should be taken 30 minutes after a meal
A. True
B. False
20. Short acting insulin begins to work
A. 30 minutes to 1 hour after taking
B. 1-2 hours after taking
C. 5-10 minutes after taking
D. 3-4 hours after taking
21. Lantus is a long acting insulin
A. True
B. False
22. Signs of hypoglycemia (low blood sugar) include:
A. Shakiness
B. Confusion
C. Hunger
D. All of the above
41
Appendix B
Diabetes Education Evaluation Form
1. What did you enjoy about today’s class?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. What did you not enjoy about the class
today?__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. What would have made the class more
enjoyable?_______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. Do you feel you learned anything new
today?__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
5. Any topics you would like to discuss in the
future?__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Other comments or suggestions____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
42
Appendix C
Program Costs
Handouts Participation Bags Prizes and Incentives
Participants
10
$250 $50 $300
Grand Total = $600